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8/16/2019 Webcast Slides Levy Time Zero
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Faculty
Mitchell M. Levy, MD, FCCMProfessor of Medicine and DivisionChief
Alpert Medical School of Brown
UniversityMedical Director, MCU
!hode sland "ospital
Providence , !hode sland
Author #$$%, #$$& ' #$(# SSC)uidelines
SCCM SSC *+ecutive and Steerin
Co--ittees
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Starting the Clock:
Time ZeroConsiderations
Mitchell M. Levy, MD, FCCMBrown University
Providence, RI
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Funded y a rant fro- the)ordon and Betty rene
Moore Foundation
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R. Phillip Dellinger, Mitchell M. Levy, ndre!Rhodes, D"illali nnane, #er!ig $erlach,Steven M. %pal, &onathan '. Sevransky,
Charles L. Spr(ng, )vor S. Do(glas, Roman
&aeschke, Ti*any M. %s+orn, Mark '.(nnally, Sean R. To!nsend, -onrad
Reinhart, R(th M. -leinpell, Derek C. ng(s,Cli*ord S. De(tschman, lavia R.
Machado,$ordon D. R(+en/eld, Steven .0e++, Richard &. 1eale, &ean2Lo(is 3incent,R(i Moreno, and the S(rviving Sepsis
Campaign $(idelines Committee incl(dingthe Pediatric S(+gro(p.
Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2012
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C(rrent S(rviving Sepsis Campaign $(idelineSponsors
• merican ssociation o/ Critical2Care
(rses• merican College o/ Chest Physicians
• merican College o/ 'mergencyPhysicians
• (stralian and e! Zealand)ntensive Care Society
• sia Paci>c ssociation o/ CriticalCare Medicine
• merican Thoracic Society
• 1ra?ilian Society o/ CriticalCare@)M1A
• Canadian Critical Care Society
• Chinese Society o/ Critical CareMedicine
• 'mirates )ntensive Care Society
• '(ropean Respiratory Society
• '(ropean Society o/ ClinicalMicro+iology and )n/ectio(s Diseases
• '(ropean Society o/ )ntensive CareMedicine
• '(ropean Society o/ Pediatric andeonatal )ntensive Care
• )n/ectio(s Diseases Society o/merica
• Indian Society of Critical Care Medicine
• International Pan Arab Critical Care Medicine
Society
• Japanese Association for Acute Medicine
• Japanese Society of Intensive Care Medicine
• Pediatric Acute Lung Injury and Sepsis
Investigators
• Society Academic Emergency Medicine
• Society of Critical Care Medicine
• Society of Hospital Medicine
• Surgical Infection Society
• orld !ederation of Critical Care "urses
• orld !ederation of Pediatric Intensive and
Critical Care Societies
• orld !ederation of Societies of Intensive and
Critical Care Medicine
Participation and endorsement#erman Sepsis Society
Latin American Sepsis Institute
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/0i-e 1ero2
• 0i-e 1ero 3 ti-e of presentation
!*D, Medical Floors, CU
• Both undles ti-e ased• Most i-portant ti-e ased ele-ents4
!Antiiotic ti-in
!!esuscitation ti-in 5*)D06
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nti+iotic therapy
(. 7e reco--end that intravenousanti-icroial therapy e started asearly as possile and within the 8rst
hour of reconition of septic shoc95(B6 and severe sepsis withoutseptic shoc9 5rade(C6.
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"ospital Mortality y 0i-e toAntiiotics
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l(id therapy
%. 7e reco--end that initial :uidchallene in patients with sepsis;induced tissue hypoperfusion with
suspicion of hypovole-nic e startedwith < ($$$ -L of crystalloids 5toachieve a -ini-u- of =$-l>9 of
crystalloids in the 8rst % to ? hours6.5)rade (B6.
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Loistic !eression Model
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SSC>@F Bundle4 Sepsis $$$
0 B* CMPL*0*D 70"@ = "U!S F 0M* FP!*S*@0A0@ 4
(. Measure lactate level
#. tain lood cultures prior to ad-inistration of
antiiotics=. Ad-inister road spectru- antiiotics
%. Ad-inister =$-l>9 crystalloid for hypotension or lactateL
/ti-e of presentation2 is de8ned as the ti-e of triae inthe *-erency Depart-ent or, if presentin fro-another care venue, fro- the earliest chart annotationconsistent with all ele-ents severe sepsis or septic shoc9ascertained throuh chart review.
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SSC>@F Bundle4 Sepsis $$$ 0 B* CMPL*0*D 70"@ ? "U!S F 0M* F
P!*S*@0A0@4
. Apply vasopressors 5for hypotension that does notrespond to initial :uid resuscitation to -aintain a -eanarterial pressure 5MAP6
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So, 7hats the ssue
• Many roups, especially *D physicians advocate foralternative ti-e Kero
! 0i-e of /dianosis2
! Physician;ased
! Chart ased
• Las
• S
• @ot all patients ad-itted fro- *D with severe sepsis presentat triae with severe sepsis
! Deteriorate in *D over hours• 0riae ti-e -ay not re:ect true /ti-e Kero2 of severe sepsis
for all patients ad-itted to CU fro- *D
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-plications for 0i-e 1ero
• @ew Nor9 State D"
! Mandated reportin of sepsis outco-es
! Adherence to /evidence;ased2 protocols
• @F sepsis -easures
! !ecently approved ! Appeal issued y ACCP>AC*P
• Fear of ein /dined2 for patients who did not -eetcriteria on triae in *D
! Pulic reportin
! Pay for Perfor-ance
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Alternatives to 0riae 0i-e
as 0i-e 1ero• 7e considered several sources in -a9in our conclusions4
! Co--ents and concerns fro- other oraniKations
represented on the #$(# SSC )uidelines Co--ittee
! *+perts on the nfectious Disease Steerin Co--ittee ofthe @ational uality Foru- 5@F6
! Pulic co--ents durin @F consensus -easuresprocess
! SSC list serve discussion
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0i-e 1ero Deter-ination4 A
Balancin Act• 0i-e Kero needs to oOer the est alance of 4 ! reliaility and reproduciility
! opti-iKin the overall perfor-ancei-prove-ent eOort as to4
(. early dianosis
#. appropriate treat-ent of severe sepsis.
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0he -portance of *arlyDetection
• *Oorts to "(st treat recogni?ed sepsis alone are inco-plete
• A critical aspect of -ortality reduction in the Ca-pain has een pushinpractitioners to identify sepsis early.
! Levy MM, Delliner !P, 0ownsend S! ,et al. 0he Survivin SepsisCa-pain4 !esults f An nternational )uideline;Based Perfor-ance-prove-ent Prora- 0aretin Severe Sepsis. Crit Care Med. #$($Fe=&5#64=?H;H%.
• t -ay well e that earlier reconition accounts for -uch of the sinal in-ortality reduction and partially e+plains sharply increasin incidence.
! )aies9i DF, *dwards QM, Rallan MQ, et al. Bench-ar9in the ncidence
and Mortality of Severe Sepsis in the United States. Crit Care Med. #$(=Fe #. *pu ahead of printT
• 7ithout reconition that the cloc9 is tic9in, there is si-ply no incentive toreconiKe a challenin dianosis early.
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Usin /0i-e of Docu-entation2 isFlawed as a Perfor-ance
-prove-ent Approach• Some patients will not meet severe sepsis criteria on ED
arrival, however altering time zero to chart annotation by a practitioner would:
! 0urn the undle into a treat-ent only undle 5not adianosis and treat-ent undle6.
! Di-inish practitioners incentives to identify patients atris9 ased on history, sy-pto-s and e+a- 8ndins at
*D presentation.
! !educe the reliaility and reproduciility of ti-e Kero.
! Ma9e data collection -ore onerous and costly.
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7here Do 0he )ains Live " B
Lead #ime to Dia$nosis Delivery o% Proper #reatment
Lead time to Dia$nosis & #reatment
o( a a r cr er on or me ?ero
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o( a a r cr er on or me ?ero+e onset o/ hypotension, !ith all
previo(s +lood press(res in the 'D
recorded as normotensiveB• Such a ti-e would4
! falsely penaliKe sites for initiation of treat-ent prior tothe onset of hypotension.
• Fluids iven 8rst A+ iven 8rst Blood culturesalready sent
! falsely decrease the nu-er of oserved cases -eetinsevere sepsis criteria.
! di-inish awareness of oran dysfunction other thanhypotension.
! not be the therapy that you want your loved one toreceive
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Fairness and the Bell Curve
• Many discussions will e had aout the /fairness2 of -a9in
providers responsile for sins ' sy-pto-s that -ay not einitially present.
• Such a viewpoint presupposes the veracity of the notion thatthe patient truly presented acutely to the *D for so-e other
reason than i-pendin Iuanti8ale severe sepsis>shoc9.
! Really??? Does that meet the test of most of the time formost cases???
• 0i-e Kero as triae will lead to earlier and -ore freIuent
reconition increased total nu-er patients withi-proved outco-es.
• Lon *D stays are another real Iuality prole- and one thathospitals should separately solve. CMS already -easuresthis prole- and there is no persuasive reason to confusethe issues.
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0he Patients Point of iew
• Despite a provider’s trueoccasional inaility to achieve theti-e sensitive indicators4
! due to late onset of sy-pto-s
! due to lon elapsed ti-e in the *D
*arly detection and treat-ent ofmy health problem is preferale.2
S i d R i l /
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Strategies and Rational /orProceeding in the et Phase o/
Sepsis E(ality )mprovement• Continue to use triae ti-e as ti-e Kero in cases presentinto the *D.
• Ma+i-iKe the undles eOectiveness for dianosis as well astreat-ent.
• Ac9nowlede a percentae of patients will not -eet criteriafor severe sepsis or septic shoc9 at *D triae and -ay -issthe undle.
• !econiKe that whatever co-pliance can e achieved will e
converted to percentiles of perfor-ance y CMS forench-ar9in.
• Ac9nowlede that ench-ar9ed perfor-ance even atpossily low levels of averae raw co-pliance will still havea top decile the decile deter-ines co-pensation in CMSsvalue ased purchasin -etrics.
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U*S0@S